The One Dozen Most Important Things You May Not Have Known, Understood, or Realized About American Medicine
Document, Document, Document! - Discussion Questions
1. What deficiency in the resident’s patient notes raises the attending’s concern?
2. Why is the sequence of the entry of information critical in this case?
3. Should the missing information be entered into the medical record now? If so, how should that be done?
4. If there had been an adverse event with respect to the spinal tap, how might the resident’s and the hospital’s liability be affected by the timing of the entry?
5. How effective was the attending in educating the resident about the importance of timely and accurate documentation? How might he have been more effective?
6. What does the resident’s final response suggest?
7. How should entry errors in medical records be corrected?
